Gaps in Payer ICD-10 Readiness Could Affect Provider Reimbursement

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A provider organization may do everything right in preparing for ICD-10—such as implementing good clinical document improvement programs and doing a top job training coders—yet still not reap the financial benefits of optimal payment under the new code set, and the fault could lie with insurers.

That could be a wrinkle in the promise of ICD-10, says John Elion, M.D, founder of ChartWise, a vendor of clinical document improvement software. For example, if a physician might perform a knee replacement surgery and properly documented all aspects of the procedure and justified the medical necessity. Everything is coded right, and the claim is sent to the payer.

But while the payer now is operating in an ICD-10 environment, its lists covering various criteria as well as eligibility and medical necessity may not have been updated and remain in ICD-9. All those various rules govern the amount of reimbursement.

Also See: Tips from Aetna on Final ICD-10 Preparations

So will you get paid under ICD-10 or ICD-9 rules? That’s a question that won’t be known until sufficient ICD-10 claims start rolling into the insurance companies and get processed. For now, “We don’t know what we don’t know yet,” Elion says.

Another possible wrinkle on the way, related to more detailed documentation, is that some ICD-9 codes don’t have an equivalent ICD-10-PCS procedure code, Elion explains.

For instance, a patient may have scar tissue from abdominal surgery, and a surgeon will go in and clean it up. Under ICD-10, the organ must be specified, so physicians have to remember to give specificity such as if the scar tissue was in the small or large bowel. But in some types of procedures to remove scar tissue, called lysis of adhesions, there is a code for ICD-9 but not a code for ICD-10, which could affect reimbursement.


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